Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
In the management of the primary site in high risk neuroblastoma, is there a role for a cone-down to residual disease (boost), following treatment of the post-chemo, pre-surgical extent to 21.6 Gy?
Patients who were enrolled in ANBL 0532 who received a 14.4 Gy boost to the primary site were compared with patients who received no boost enrolled on COG A3973. Five year CILP (cumulative incidence of local progression), EFS, and OS were the same between the two groups of patients. This was present...
How do you approach the decision of whether and when to initiate therapy in patients who remain COVID-19 positive >2 weeks after infection but are asymptomatic from the virus?
If the patient is asymptomatic or minimally symptomatic, we have elected to initiate therapy for the patient. We have treated the patient in full PPE at the end of the day with no other patients in the clinic. Efforts should be made to minimize patient contact throughout the clinic. We have the pat...
How should patients be selected for metastatic-site directed radiotherapy in rhabdomyosarcoma?
Definitive therapy to sites of metastases at the time of diagnosis is recommended for all patients with metastatic disease on the most recent COG trials (both ARST1431 including intermediate risk patients and ARST0431 including high risk patients). We typically treat the metastatic sites at the end ...
When treating an intact whole breast using breath-hold technique with a planned electron boost, do you generate a separate plan for the boost with a free-breathing scan, or plan the electron boost on the breath-hold scan, but treat free-breathing?
It is our practice to acquire a free breathing and breath hold scan. I evaluate the boost plan on the free breathing. The "plan sum" is on the breath hold, but I would be reluctant to not have the free breathing for evaluation of dose, particularly on the left side, as the cardiac displacement may s...
How do you manage dental extractions in a patient getting reirradiation to the mandibular area?
Taking into account the poor prognosis of re-irradiated HNC (for example, Ward MC et al, Oral oncology 2019, reported in a recent 9-institution study of more than 500 patients, cancer progression or death in 64% after re-irradiation), teeth/mandibular damage risk is a moot issue. If cancer is eradic...
How would you approach a locally advanced, node positive oral cavity squamous cell carcinoma of the H&N with cCR after induction chemotherapy?
I would use consolidative full-dose chemo-RT to the pre-chemo CTVs. I would not reduce the extent of the CTVs or treatment intensity. Before the TPF era, randomized studies of induction followed with RT vs RT alone in HNC did not result in improved outcomes in the induction arms, despite achieving a...
Would you consider post-operative radiation therapy for resected malignant melanoma with in-transit metastasis?
I don’t know of any evidence that RT is helpful in this situation.
Would you radiate a multiply recurrent basal cell adenoma of the parotid?
Yes, after gross total resection with carcinoma doses.
Would you consider preoperative radiation for a retroperitoneal sarcoma in a patient with Li Fraumeni syndrome where upfront surgery is likely to yield a positive margin?
This is a scenario where multi-disciplinary discussion is key. First, what is the histology of the RP sarcoma? Second, where is the likely positive margin, and do we expect potential downstaging with RT to impact this margin? Consideration for systemic therapy with restaging and consideration for RT...
How do you approach SRS to a thalamic metastasis?
I am not aware of high-quality data to guide us here, but there is abundant published retrospective experience. A model by Flickinger et al. predicted higher toxicity rates after SRS in AVM patients for brainstem and other deep locations. That said, low toxicity has been reported for treatment of AV...